NURS120 WK 3 Fractures & Pressure Ulcers
Stage 3 pressure injury
-FULL thickness skin loss -Extends into the underlying subcutaneous tissue layer -Deep crater with or w/o tunneling -Bone tendon is NOT visible
Stage 4 pressure injury
-FULL thickness tissue loss -Extends to muscle, bone, or supporting structures -Bone, tendon, or muscle MAY be visible or palpable -Scab like material may be present on some parts of the wound bed: slough (tan, yellow), eschar (black) -Deep pockets of infection
Stage 1 pressure injury
-NON-blanchable redness -Intact skin -Warmer or cooler vs adjacent tissue -Bony prominence
Stage 2 pressure injury
-PARTIAL thickness skin loss -Looks like abrasion or blister -Slough/scar is NOT present
Skin traction
-Short-term (48-72 hours) -Tape, boots, or splints applied directly to skin -Traction weights 5 to 10 pounds -Skin assessment and prevention of breakdown
Unstageable pressure injury
-Stage can not be determined -eschar/slough obscures the wound -Actual depth of injury is unknown
Bisphosphonates
-dronate Decrease osteoclast number and actions, used for prevention and tx of osteoporosis
The client must take three (3) grams of calcium supplement a day. The medication comes in 500-mg tablets. How many tablets will the client need to take daily? _______
6
What to teach the pt in regrds to casts
Avoid placing foreign objects inside the cast, blow cool air from hair dryer to relieve itching, cover cast with plastic if needed to avoid soiling from urine or feces, demonstrate how to use plastic bag to cover during baths and showers, report any areas under the cast that are hurting, warm to the touch, have an odor or increased drainage. Report any change in mobility, SOB, skin breakdown or constipation.
A licensed practical nurse is reporting observations and cares to a registered nurse. Based on report, which client should RN assess immediately? A. The client, 2 hrs following a total knee replacement, who hs 100 ml of bloody drainage in the suction container of an autotransfusion drainage system. B. The client with a crushed injury to the arm who was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain C. The client in a new body cast who was turned every 2 hrs and supported with waterproof pillows D. The client with an external fixator on the leg having serous drainage from the pin sites
B.
A male client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the best clinical judgement by a nurse? A. Immediately notify the physician B. Initiate oxygen at 2 liters per minute per nasal cannula to relieve dyspnea C. Places ice packs around the cast to reduce the abdominal distention D. Administers ondansetron the prescribed antiemetic on the clients MAR
B.
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? A. Place the wheel chair at a 90 degree angle B. Lock the wheels of the bed and wheel chair C. Acquire the help of several people to lift the client D. Elevate the bed to a position comfortable for the nurse
B.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. B. Ensure the weights of the Buck's traction are off the floor and hang freely. C. Raise the head of the bed to 45 degrees and the foot to 15 degrees. D. Turn the client on the affected leg using pillows to support the other leg.
B.
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit? A. Severe bone deformity. B. Joint stiffness. C. Waddling gait. D. Swan-neck fingers.
B.
The client is three (3) hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? A. Explain to the client his left leg has been amputated. B. Medicate the client with a narcotic analgesic immediately. C. Instruct the client on how to perform biofeedback exercises. D. Place the client's residual limb in the dependent position.
B.
The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? A. "This position will help your lungs expand better." B. "Lying on your stomach will help prevent contractures." C. "Many times this will help decrease pain in the limb." D. "The position will take pressure off your backside."
B.
The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaborative problem has the highest priority? A. Impaired cognition. B. Altered nutrition. C. Self-care deficit. D. Altered coping.
B.
Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. A. Apply an immobilizer snugly to prevent edema. B. Apply an ice pack for 10 minutes and remove for 20 minutes. C. Place the extremity in the dependent position to allow drainage. D. Obtain an x-ray of the ankle after applying the immobilizer. E. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.
B. E.
Greenstick fracture
Bending and incomplete break of a bone; most often seen in children
A nurse is providing instructions to a client who has a plaster cast to attain adequate molding following a fracture to the right wrist. Which statement, if made by the nurse is incorrect? A. Keep your cast uncovered while drying so that moisture can evaporate B. Your cast will have a musty odor and dull gray appearance until it dries. But once dry, your cast should be shiny white and odorless C. Your cast will feel sticky and very warm during the drying process, but it will dry very quickly in about 30 minutes D. Support the cast by elevating on pillows and avoid any sharp or hard surfaces, especially while your cast is drying, because it can cause denting and pressure areas
C.
An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first? A. Insert an indwelling catheter. B. Administer a Fleet's enema. C. Assess the abdomen for bowel sounds. D. Apply Buck's traction.
C.
The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)? A. Allow the client to stay in bed until the pain becomes bearable. B. Tell the UAP to give the client a bed bath this morning. C. Try to encourage the client to get up and go to the shower. D. Notify the family the client is refusing to be bathed.
C.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? A. X-ray of the femur. B. Serum alkaline phosphatase. C. Dual-energy x-ray absorptiometry (DEXA). D. Serum bone Gla-protein test.
C.
The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? A. Keep the skin moist by leaving the skin damp after the bath. B. Do not rub any lotion into the skin. C. Turn clients who are immobile at least every two (2) hours. D. Only the licensed nursing staff may care for the client's skin.
C.
The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? A. Dependent edema B. Diminished pedal pulses C. Presence of hot spot on the cast D. Coolness and pallor on extremity
C.
The nurse is caring for clients on a medical unit. After the shift report, which client should the nurse assess first? A. The 34-year-old client who is quadriplegic and cannot move his arms. B. The elderly client diagnosed with a CVA who is weak on the right side. C. The 78-year-old client with pressure ulcers who has a temperature of 102.3 F. D. The young adult who is unhappy with the care that was provided last shift.
C.
The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a non-modifiable risk factor? A. Calcium deficiency. B. Tobacco use. C. Female gender. D. High alcohol intake.
C.
The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care? A. Keep the fractured arm at heart level. B. Use a wire hanger to scratch inside the cast. C. Apply an ice pack to any itching area. D. Explain foul smells are expected occurrences.
C.
The nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcers. Which interventions should be included in the plan of care? Select all that apply. A. Turn the client every three (3) to four (4) hours. B. Ask the dietitian to consult. C. Have the client sign a consent for pictures of the wounds. D. Obtain an order for a low air-loss bed. E. Elevate the head of the bed at all times.
C.
Drugs to treat phantom limb pain
Calcitonin, beta blockers, anticonvulsants, and antispasmodics
Osteoporosis tx
Calcium and Vit D used for prevention
Promotion and prevention of fractures
Calcium and Vit. D, sunlight exposure (10-4 NEED sunscreen), screen for osteoporosis (usually > 65 y/o), weight-bearing exercise (walking), bisphosphonates, fall/injury prevention
How do you immobilize a fracture?
Casting or splinting, traction, external fixation, internal fixation
Pin site care
Chlorhexidine, one cotton swab for each pin, once a shift, 1-2 times a day
The client diagnosed with stage IV infected pressure ulcers on the coccyx is scheduled for a fecal diversion operation. The nurse knows that client teaching has been effective when the client makes which statement? A. "This surgery will create a skin flap to cover my wounds." B. "This surgery will get all the old black tissue out of the wound so it can heal." C. "The surgery is important to allow oxygen to get to the tissue for healing to occur." D. "Stool will come out an opening in my abdomen so it won't get in the sore."
D.
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the clients sacral area? A. Intact skin B. Full thickness skin loss C. Exposed bone, muscle and tendon D. Partial thickness skin loss of the dermis
D.
The nurse is one of several persons who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. Which intervention should the nurse take? A. Try to reduce the fracture manually B. Assist the victim to get up and walk to the sidewalk C. Leave the victim for few minutes to call an ambulance D. Stay with the victim and encourage the person to remain still.
D.
What is the scientific rationale for placing lift pads under an immobile client? A. The pads will absorb any urinary incontinence and contain stool. B. The pads will prevent the client from being diaphoretic. C. The pads will keep the staff from workplace injuries such as a pulled muscle. D. The pads will help prevent friction shearing when repositioning the client.
D.
Which order written by a physician should be a priority for a nurse caring for a client who sustained an unstable pelvic fracture in a motor vehicle accident? A. Urinalysis B. Blood alcohol level C. CT scans of pelvis D. Two units of cross-matched blood
D.
S/S of fat ambolism
Dyspnea, increased RR, decreased mental acuity, tachycardia, confusion, chest, pain, LATE SIGN: cutaneous petechiae
Clinical manifestations of a fracture
Edema and swelling, pain and tenderness, muscle spasms, deformity, ecchymosis and contusions, loss of function, crepitation (sound of crackling in the joints)
Treatment of compartment syndrome
Fasciotomy, open wounds, negative pressure wound therapy
Vit D rich foods
Fish, egg yolks, fortified milk, cereal
Comminuted fracture
Fracture in which the bone is crushed
Phantom limb pain
Frequent complication of amputation, pt complains of pain at the site of the removed body part, pain is intense burning feeling, crushing sensation or cramping, pt might feel like the removed body part is in a distorted position
Fiberglass casts
Light, stronger, water-resistant, takes 30 minutes to dry
Health promotions for osteoporosis
Limit carbonated beverage, sun exposure (5-30 minutes twice a week), avoid sedentary lifestyle (weight bearing exercises, walking)
Skeletal traction
Longer period using pin or wire, applied directly to bone, PIN SITE CARE, traction weight 15-30 lbs
Risk factors for osteoporosis
Loop diuretics, corticosteroids, thyroid medications, anticonvulsants, COPD, RA, diabetes, hyperthyroidism
Nursing care for fat embolism
Maintain bed rest, immobilize, minimal manipulation. TX: oxygen, corticosteroids, vasopressors, fluid replacement for shock, anti anxiety medication as needed
Traction care
Maintain body alignment, avoid lifting or removing weights, ensure weight hangs FREELY, NOT resting on the floor, replace weights if accidentally displaced (priority), ensure that ropes are free of knots, fraying, loosening or improper positioning at least every 8-12 hrs, if pt has SEVERE pain, notify the provider, and that patient has trapeze bar
What are the different ways to realign the bones in a fracture?
Manipulation, closed reduction, skin traction, skeletal traction, open reduction
Calcium rich foods
Milk products, green vegetables broccoli, fortified orange juice, cereals, red and white beans, figs
Nursing actions for casts
Monitor neurovascular status q hour for first 24 hrs and assess pain, handle wet plaster with PALMS not FINGERTIPS to prevent denting, elevate cast above the level of the heart to prevent edema, room for one finger between the skin and cast, document presence of drainage or increase in drainage
TDAP
Only for adults
DDAP
Only for children
Fracture risk factors
Osteoporosis (excessive exercise or weight loss:anorexia, menopause, long term corticosteroids), falls, MVA, substance use disorders, diseases (ricketts, pagets), contact sports (football), physical abuse, lactose intolerance and age (elderly)
Braden scale
The lower the score, the higher the risk -Very high risk: 9 or < -High risk: 10-12 -Moderate risk: 13-14 -Mild risk: 15-18 -No risk: 19-23
Compartment syndrome
involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles. Pain not relieve by analgesics, intense pain when passively moved, compromised circulation
The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client? A. Take the medication on an empty stomach. B. Make sure to taper the medication when discontinuing. C. Apply the medication topically over the affected joints. D. Notify the health-care provider if vomiting blood.
D.
Neurovascular assessment
(5 P's): Pain, Pulse, Pallor, Paresthesia, Paralysis Every hour for the first 24 hrs, then every 1-4 hrs
The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. A. Report any pain not relieved with analgesics. B. Eat a well-balanced diet and increase protein intake. C. Be sure to attend all outpatient rehabilitation appointments. D. Encourage the client to attend a support group for amputations. E. Stay at home as much as possible for the first couple of months.
A. B. C. D.
Spiral fracture
A fracture in which the bone has been twisted apart
The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply. A. Numbness and mottled cyanosis. B. Paresthesia and paralysis. C. Proximal pulses and point tenderness. D. Coldness of the extremity and crepitus. E. Palpable radial pulse and functional movement.
A. B. D.
Stress fracture
A small crack in the bone that often develops from chronic, excessive impact
In case of swelling what can be done?
A univalve or bivalve incision
A nurse is assessing an elderly client in Bucks traction to temporarily immobilize a fracture of the proximal femur prior to surgery. Which findings requires the nurse to intervene immediately? A. Reddened area on the sacrum B. Voiding concentrated urine @ 50 mL/hr C. Capillary refill time 3 seconds, dorsiflexion and sensation intact, pedal pulses palpable D. Lower leg secure in traction boot and ropes and pulleys and 5 lb weight hanging freely
A.
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment B. Explain the discharge instructions to the client and parents C. Provide reassurance to the client and parents D. Apply an ice pack to the casted leg
A.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? A. Assess the client's nutritional status. B. Refer the client to an occupational therapist. C. Determine if the client is allergic to IVP dye. D. Start a 22-gauge Angiocath in the right arm.
A.
The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? A. Assess the nail beds for capillary refill time. B. Remove the client's clothing from the arm. C. Call radiology for a STAT x-ray of the extremity. D. Prepare the client for the application of a cast.
A.
The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? A. The client with a total knee replacement who is complaining of a cold foot. B. The client diagnosed with osteoarthritis who is complaining of stiff joints. C. The client who needs to receive a scheduled intravenous antibiotic. D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
A.
The nurse is developing a plan of care for a client diagnosed with left-sided paralysis secondary to a right-sided cerebrovascular accident (stroke). Which should be included in the interventions? A. Use a pillow to keep the heels off the bed when supine. B. Order a low air-loss therapy bed immediately. C. Prepare to insert a nasogastric feeding tube. D. Order an occupational therapy consult for strength training.
A.
The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA? A. Being overweight. B. Increasing age. C. Previous joint damage. D. Genetic susceptibility.
A.
The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "fatty globules" floating in the urinal. What intervention should the nurse implement first? A. Assess the client for dyspnea and altered mental status. B. Obtain an arterial blood gas and order a portable chest x-ray. C. Call the HCP for a ventilation/perfusion scan. D. Instruct the UAP keep the client on strict bedrest.
A.
Which signs/symptoms indicate to the nurse the client has developed osteoporosis? A. The client has lost one (1) inch in height. B. The client has lost 12 pounds in the last year. C. The client's hands are painful to the touch. D. The client's serum uric acid level is elevated.
A.
Treatment goal for fractures
Anatomical realignment
Risk factors of pressure injuries
Advanced age, anemia, DM, elevated body temp, decreased leukocyte, vascular disease, obesity, smoking, immobility/incontinence
Contributing factors of pressure injuries
Amount of pressure, duration of pressure, the ability of tissue to tolerate externally applied pressure, shear, friction and moisture
The 84-year-old client is a resident in a long- term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? A. Keep the bed in the high position. B. Perform passive range-of-motion exercises. C. Turn the client every two (2) hours. D. Provide nighttime lights in the room.
D.
What type of fracture is at more of a risk for infection? Simple or complexed
Complexed
A client is suspected of having a fat embolism following a pelvic fracture from a motor vehicle accident. A nurse should assess for which sign that is specific to fat emboli? A. Dyspnea B. Chest pain C. Delirium D. Petechiae
D.
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care? A. Ask the client to move her arms and legs while applying slight resistance. B. Move the clients limbs through their complete range of motion C. Have the client move each limb independently through its complete range of motion D. Instruct the client to tighten muscle groups for a short period then relax.
D.
Plaster casts
Heavy, NOT water resistant, takes 24-72 hrs to dry
Fat embolism
Hip and pelvis fractures are common causes, 12-48 hrs following long bone fractures or with total joint arthroplasty
How to take biphosphonates
In the morning, with 8 oz of water, and MUST stand for 30 minutes after.
S/S of compartment syndrome
Increased/unrelieved pain, paresthesia or numbness, paralysis or weakness, pale skin/cyanotic nail beds, hardened muscles, and pulselessness is a LATE manifestation
Oblique fracture
Occurs at an angle across the bone
Transverse fracture
Occurs straight across the bone
Shear force on pressure injuries
Pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement
Pressure injury or cubitus ulcer
Pressure ulcers
Assessment of pressure ulcer
Pt should be reassessed every 24 hours in acute care, in long term care pt should be reassessed weekly for the first 4 wks after admission then minimally monthly or quarterly
Tractions
Pulling force to promote and maintain alignment. Appropriate rx: type, amount of weight, if can be removed for nursing care. #1 risk is infection
Exercise after amputation
ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial
Nursing care for amputations
Relieve pain, minimizing altered sensory perception, promoting wound healing, enhancing body image and self care
How do you care for open fractures?
Surgical debridement, tetanus and diphtheria immunization, prophylactic antibiotics, immobilization
Most common sites for pressure injuries
Sacrum and heels
Factors of assessment using braden scale
Sensory perception, moisture, activity, mobility, nutrition and friction and shear
What is the best way to diagnose a fracture?
Xray or CT
